Dr. Keebler

Dr. Mary Keebler, Medical Director of the UPMC Advanced Heart Failure Center discusses the options and groundbreaking, individualized care available for patients dealing with advanced heart failure.

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-This podcast is for informational and educational purposes only. It is not medical care or advice. Clinicians should rely on their own medical judgments when advising their patients. Patients in need of medical care should consult their personal care provider.

– Providing hope and state-of-the-art care for heart patients: welcome to the UPMC HealthBeat Podcast. I’m Tonia Caruso, and joining us right now is Dr. Mary Keebler. She’s the medical director of the UPMC Advanced Heart Failure Center, which is part of the UPMC Heart and Vascular Institute. Dr. Keebler, thanks so much for joining us.

– Thanks for having me.

– So let’s begin with the basics and tell folks about the Advanced Heart Failure Center and why and how it came together.

– The Advanced Heart Failure Center has existed at UPMC for many years. It includes a comprehensive and multidisciplinary team of doctors and nurses and social workers and other medical personnel to take care of patients with advanced heart failure. We focus on everything from medical management, all the way up to state-of-the-art techniques to help patients with advanced heart failure when medications no longer work.

– And let’s give patients a sense when they come to the center, sort of the process and what happens and how they’re evaluated and how their course of treatment is decided.

– Patients come to us in many different ways. Some are referred to us by their primary care doctors, some by their cardiologists, and others just on their own seeking an expert opinion in heart failure management. Patients are evaluated in initially a very traditional way, in that they are seen in a clinic with a doctor who specializes in heart failure. And we talk about the patient’s journey with the disease: what their symptoms are, what medications are working, what medications aren’t working, and then we adjust those medications to fit those patient’s needs as best we can. From there, if we determine that patients are not benefiting from medications, then we will proceed to what we call an advanced heart failure evaluation, which includes a very comprehensive head-to-toe evaluation to determine whether the patient might be a candidate for an advanced therapy, such as a heart transplant or a ventricular assist device. During this evaluation patients meet not only with their doctors, but they also meet with specialized nurses who focus on heart transplant and ventricular assist device care. They will meet with social workers, pharmacists, nutritionists — a whole group of people who are really trained and specialized and knowledgeable in managing these types of patients. At the completion of the evaluation, we all get together as a team, and we review each patient in detail and come up with the best treatment plan for that patient. Sometimes that treatment plan and that recommendation will be a heart transplant. Sometimes that may be a ventricular assist device, either as a means to get to a heart transplant or for what we call destination therapy, which means that the patient will be on support for the remainder of their lives. And lastly, we may recommend that the patient’s not healthy enough to go through a big surgery like this. And then we work closely with our palliative care colleagues to give them the best quality of life for as long as we possibly can.

– Let’s tell folks a little bit more about the ventricular assisted device and what that is and how that works.

– A ventricular assist device is a surgically implanted pump that goes in the tip of the left side of the heart. The pump itself takes over the work of the left side of the heart. There is then a long tube that we call the drive line that comes outside of the skin and connects to the computer and the battery supply on the outside of the body. Ventricular assist devices have become really one of the mainstays of treatment for advanced heart failure. They’ve come a long way over the past 20 years, and patients are now able to live pretty full lives while on ventricular assist device support. The goal of ventricular assist device management is not only to improve quantity of life, which they certainly do, but also to improve quality of life for patients. Patients who can’t stay out of the hospital because they are continually coming in with fluid volume overload because they can’t breathe and their legs are swelling suddenly have the opportunity to live life rather than just watch it pass them by. They’re able to get dressed without feeling shortness of breath. They’re able to go on vacation. They’re able to do things that really haven’t been possible for them to do for a very long time. And most importantly, to stay out of the hospital and at home with their family and friends.

– And you also said that sometimes that is a bridge to transplantation. Now let’s talk about transplantation and the role that it plays and really kind of the hope that it can give patients.

– Sure. So I always say that transplantation is a way of turning a tragedy into a miracle, and for patients who have the gift of life through organ donation and subsequent transplantation, this is a real life-changer for them. So transplant continues to be the most effective way, the way with the most longevity, of helping patients live longer when their hearts just no longer work and don’t respond to medical therapy. Organ donation is something that is very challenging in the current environment. Certainly with COVID we have had several challenges with transplant, but here at UPMC, we have been able to overcome many of those challenges and continue to offer patients with end-stage heart disease a chance of life with heart transplantation.

– And why is it so key or so important that UPMC consistently does high numbers of transplants for both heart transplants and heart and lung transplants? Why is that important when it plays into a patient’s outcomes?

– Many things can happen after a transplant. Sometimes the road is easy, and sometimes it’s very challenging. And you want a team that has seen it all before, that knows how to manage patients through all the potential complications that can happen after a transplant. We want these patients to have success with their hearts. And like I said, sometimes it’s easy, but sometimes the road is challenging. Whether that road begins in the operating room, where they may have additional challenges because of prior surgeries that make the organ transplant itself more difficult. You want the patient to be in the most capable hands, the most experienced hands, and our surgeons certainly have those skills. Then after transplantation, there can be several complications that happen from medications. Just from having the immune system suppressed, patients can be prone to infections. They can be prone to worsening kidney disease and diabetes. And you want to have experienced doctors that have done this for many years, with many patients, to take care of your family member or for yourself, so again that you can have the best possible outcome.

– And really one of the advantages of coming to the Advanced Heart Failure Center is that you’re already involved with the team, and so you can sort of prepare. Because I would imagine in other instances, such as kidney donations and liver transplants, there’s the opportunity for living donor. How important is it to get people on track and thinking of that way of perhaps long-term a transplant?

– So you make a very good point in that we have the opportunity in the Advanced Heart Failure Center to develop a relationship with patients before they go to transplant. And that’s really what we’re doing in the very early stages, when we’re working with patients to optimize their medical therapy. We are also learning about the patient, learning about their families, what’s important to them. And then as we get to transplantation or ventricular assist device implantation, we know the patient, we know the families, we know what’s important to them, and that way we can give those patients the best treatment possible because we know them not only from their disease and their medical illness, but what’s important to them as a person. And that is so critical for an important and meaningful outcome.

– And always looking for new advances in all aspects of treatment. You’re now using data in some areas to try to predict who might need some help.

– That’s right. So, we are using data available through the UPMC health system to help identify pockets of patients that have risk factors for developing advanced heart disease, whether they have been admitted to the hospital multiple times in the past six months or over the past year, whether they are not tolerating medications well that we know help patients live longer. These are some of the things that we look at in terms of predicting who may require advanced heart failure consultation and advanced therapies down the road.

– And, doctor, you’ve touched on this already in our conversation about COVID and how COVID has impacted care. So UPMC, you continue to do the work, and transplants continued to take place during COVID, correct?

– That is right.

– And so what do you want to say to patients about why it’s important that they keep their health care on track not only when it comes to transplantation, but people who would attend the center.

– First of all, UPMC, I think, has done a phenomenal job in making sure our hospitals are safe for patients to come to. This goes for clinics as well. When you come to the clinic or to the hospital, you, as well as every staff member that comes into the hospital, will answer questions about any exposures you might’ve had to COVID and any symptoms that you might have. You also have your temperature taken. If you don’t pass that screen, you’re not able to come into our facility. And again, that goes for our staff, our physicians, our nurses, our front desk staff, everyone that enters the building. And then each person has given a mask and is required to wear that mask at all times. This is critical for keeping our patients safe and healthy, as well as our team members. So I just want to reiterate that it’s a very safe thing to do to come to the hospital and to see your doctor. When you come into the waiting room, you may notice that there are much fewer chairs because we are socially distancing in waiting rooms. We’re also limiting the number of patients into the clinic and the number of staff members into the clinic: again, to limit exposure. Now, we are also using video visits, which enables us to see patients, to have our visits with patients, and to talk about how they’re doing. We can see on the video how healthy they are. Even we are taking in as we’re having those conversations how fast they’re breathing and how easy it is to have a conversation. We go through the medications, and we talk about their treatment plan. And that’s a very effective way of keeping patients safe at home without coming into the clinic, particularly if they are stable. However, if patients are feeling more short of breath or having more swelling or more difficulty with their heart failure management, that can be pretty challenging to manage over a video. And for those patients, we really want to see them in the clinic, where we can do a comprehensive and thorough clinical exam. We can get necessary laboratory testing and maybe some other testing to help us figure out what’s going on with the patient and how to help them feel better. If that is necessary, again, we have a very safe environment for patients and their families to come into the hospital, into the clinic, for us to help them get better.

– Right. And you see some very complex cases in the clinic. For the general public who might be watching or listening to this, what are some of the early signs and symptoms of heart issues? What should people be paying attention to? And what do you want to say about beginning a conversation about care, even with just their PCP?

– So I think one of the earliest warning signs that there might be something going on with your heart or your lungs is just that you notice that you can’t do what you used to be able to do. If you think back to six months ago, which for right now would be around Christmas time, what types of activities were you able to do? If you were able to go shopping, to the grocery store, to go for walks around the block with your family, maybe to walk your dog and that was pretty easy then. And all of a sudden it feels very challenging and you feel like you just can’t catch a breath, maybe a walk around the block that used to take 10 minutes now takes 30 minutes because you have to stop so often to catch your breath. That’s a warning sign that something is going on, either with your heart and your lungs, and you would need to talk about that with your primary care provider. You might also notice swelling in your legs or swelling in your belly. That could be fluid accumulating, and that can be due to heart failure: again, that something is wrong with your heart. That would be another important warning sign.

– Well, Dr. Mary Keebler, some great information. We thank you so much for your time today. We certainly do appreciate it.

– Thank you for having me.

– And I’m Tonia Caruso. Thank you for joining us. This is UPMC HealthBeat.

About Heart and Vascular Institute

The UPMC Heart and Vascular Institute has long been a leader in cardiovascular care, with a rich history in clinical research and innovation. As one of the first heart transplant centers in the country and as the developer of one of the first heart-assist devices, UPMC has contributed to advancing the field of cardiovascular medicine. We strive to provide the most advanced, cutting-edge care for our patients, treating both common and complex conditions. We also offer services that seek to improve the health of our communities, including heart screenings, free clinics, and heart health education. Find an expert near you.